Amenorrhea Overview

Amenorrhea (missed periods) is the absence

of menstrual bleeding. In females of
reproductive age, diagnosing amenorrhea is a
matter of first determining whether pregnancy
is the cause for this condition. If pregnancy is
not present, the challenge is finding the exact
cause of the absent periods. The problem
may be either primary or secondary. Primary
amenorrhea is a delay in or a failure to start
menstruation; secondary amenorrhea is an
unexpected cessation of the menstrual cycle.

Normal menstrual cycles rely on a complex

feedback system between the hypothalamus,
the pituitary gland, the ovaries, and the
cyclical reaction of the lining in the uterus to
sex hormones (See graphic).

Amenorrhea (missed periods) is the absence of

menstrual bleeding.

Possible causes of amenorrhea include:

 Abnormalities in the uterine lining, such as birth defects, infection and poor
response to hormones;
 Ovarian dysfunction, such as premature ovarian failure and tumors;
 Pituitary dysfunction due to factors like tumors and postnatal injuries;
 Hypothalamus dysfunction caused by birth control pills, emotional and physical
stress;
 Other endocrine disorders arising from the adrenal glands, thyroid or pancreas.

Amenorrhea (Missed Periods) in Traditional Chinese Medicine

In Traditional Chinese Medicine (TCM),
menstrual problems are a matter of
serious concern. This is partly because
in ancient China, childbearing was the
most important role that a woman had,
and normal regulated menses signified
that she could give birth to healthy
babies.

Menstruation, pregnancy, childbirth

and lactation are unique to women.
Blood is the elementary basis of these
physiological functions hence there is
the saying that "for women, blood is
paramount." Women's diseases have
been seen as a unique specialty far
back in history with the first
gynecological monograph Jingxiao Classic illustration showing different kinds of women's
Chanbao (Tested Treasure in conditions such as infertility, irregular menses and weakness
Obstetrics) being published in AD 847- after delivery.
859 by Zan Yin. Among these literary
works, menstrual problems such as
heavy menses, scanty menses, early
or delayed periods, prolonged periods,
missed periods and menstrual
crampingand so on, are categorized in
detail.

Records about missed periods can be tracked back 2000 years to the Huang Di Nei
Jing (Yellow Emperor's Internal Classic), in which there was a prescription with
cuttlefish bone as the main ingredient for amenorrhea due to "withered blood."
Ancient physicians believed that amenorrhea resulted from various disturbances in
the interactions between the kidneys, tian gui, extra meridians
(Thoroughfareand Conception Vessels) and the Uterus. Dysfunction in
the spleen and liver also play a major role during the development of amenorrhea.
The disharmonies interfere with menses formation in the uterus and lead to missed
periods.

Click to see the Women's Physiology from a TCM perspective. TCM

Understanding of Women's Physiology

TCM understands the gender variation in physiology and disease development.

Therefore, during consultation it is necessary to consider these differences and to pay
attention to the characteristics of women's diseases.

Generally, men and women's organs, meridians, blood and qi (vital energy)have
similar activities but women have special physiological structures like the uterus that
affect menstruation, pregnancy, childbirth and lactation. These organs especially
need blood and qi (vital energy) to function with the meridians acting as
communicating channels. As a result, the physiological functions are dependent upon
the promotional effects of the organs, meridians, blood and qi (vital energy) working
together.

The Extra Eight Meridians

Normal physiological functioning also depends on the proper regulation of the

standard nomenclatures of the eight meridians. Because the majority of uterine qi and
blood travels within these meridians, the relationship of the uterus and the extra
meridian network is extremely close.

The extra eight meridians include the Governor Vessel, Conception Vessel,
Thoroughfare Vessel, Girdling Vessel, Yin Link Vessel, Yang Link Vessel, Yin
Heel Vessel and Yang Heel Vessel. Unlike the twelve regular meridians, these
eight vessels are not distributed regularly but are situated in a rather complex pattern
among the regular meridians. Their main function is to strengthen the links between
the twelve regular meridians and to regulate qi and blood circulation. They have
special relationships with the liver, kidney, uterus, brain and marrow and thus
influence these structures physiologically and pathologically. These vessels do not
possess direct connections or interior-exterior relationships with the zang
organsand fu organs.

The Governor Vessel (du mai) originates from the

perineum just before the anus, runs in the midline up along
the spinal column and reaches the head finally. This
meridian meets all the Yang meridians, thus is called the
"sea of the yang meridians." It is responsible for governing
the qi for all the yang meridians of the body. This vessel
has close relationships with the brain, spinal cord and
kidney respectively. Since it communicates with the brain,
it can be regarded as a link similar to the pituitary-adrenal
axis in Western medicine. In women, this vessel makes
blood exit the body during menstruation. Governor Vessel

The Conception Vessel (ren mai) originates from

the perineum, runs along the anterior midline of the
abdomen, passes through the cheek and enters into the
eye socket finally. It meets all the yin meridians, and thus
is called the "sea of the yin meridians." It is responsible for
receiving and bearing the qi of the yin meridians. In
women, this meridian is thought to originate in the uterus
where the fetus is nourished, thus there is a saying that
"the Conception Vessel dominates the uterus and
pregnancy." It provides yin substances for all women's
physiological activities. Conception Vessel
 The Thoroughfare Vessel (chong mai)originates
in the pelvic cavity and runs alongside the kidney
meridian up to the thorax. It is regarded as the “sea of
blood," which is the place for the twelve regular
meridians to converge and where it helps regulate the qi
and blood inside them. This vessel influences the supply
and proper movement of blood in the uterus, and is
closely related to the menses. The main difference
between the Thoroughfare Vessel and Conception
Vessel in relation to menstruation is that the Conception
Vessel controls qi and can be used to tonify and nourish,
where as the Thoroughfare Vessel controls blood, and is
used to move qi and blood and to remove obstructions. Thoroughfare Vessel

The Girdling Vessel (dai mai) originates below the

rib side, runs down along the lateral side of loin and
encircles the waist. It passes through the uterus like a
girdle. The Girdling Vessel retains the meridians of the
entire body, promoting their interconnected relationships.
In women, it also takes charge of nourishing and
lubricating the uterus and controls vaginal discharge.

Girdling Vessel

The Female Reproductive System

In TCM anatomy, the female reproductive system consists of the uterus, cervix,
birth canal, vaginal orifice and the surrounding meridians. The uterus, also called
the "child's palace," lies in the lower abdomen, in the center of pelvic cavity,
behind the urinary bladder and in front of the rectum. Its lower opening connects
with the birth canal. The primary function of the uterus is to produce menses and
to cultivate the fetus.

1. Producing menses:
Menstruation is formed in the uterus. When a woman reaches puberty,
her uterus matures and her kidney essence is enriched to a certain
extent. The kidneys then will produce a type of substance for promoting
sexual functions, which is called tian-gui. Under the action of this
substance, the Conception Vessel and Thoroughfare Vessel are
exuberant and flushed with abundant qi and blood. The excessive qi and
blood will empty into the uterus and produce regular menses. In old age,
the kidney essence is exhausted and tian-gui declines. The Conception
Vessel and Thoroughfare Vessel gradually close and become obstructed.
A woman then begins to have menstrual irregularities until menopause
occurs.
2. Cultivating the fetus:
Once a woman's uterus is fully developed, and her menses are regular.
 She has the ability to become pregnant and give birth. When an egg from
her ovary is fertilized with a sperm, pregnancy will result. From a TCM
understanding, this process involves the combination of congenital
essences from both sexes, which are transmitted into the embryo in the
uterus. Thereafter, the uterus supplies the nutrients for the growth and
development of the fetus until childbirth.

Additionally, physiological functions of the uterus are associated with

the heart,liver, spleen and kidneys as well as the Conception and Thoroughfare
Vessels. This is because producing menses and cultivating a fetus rely on the
nourishment of blood and promotion of the kidney essence. These nourishing
substances are regulated and supplied by the following TCM concepts:

 The heart rules the blood.

 The liver stores the blood.
 The spleen governs the blood.
 The kidneys store essence.
 The Conception and Thoroughfare Vessels control qi and blood in the uterus.

Therefore, only when the organs and meridians function well can the uterus work
normally. Pathologically, disorders in the above organs and meridians will affect the
uterus resulting in menstrual disorders and possibly sterility. In the treatment of
women disorders, TCM often focuses on nourishing these organs, and tends to
particularly replenish blood.

Note: From the foregoing physiology and pathology of the uterus, it can be seen that the uterus in
TCM encompasses not only to the womb but also the whole internal genital system.

In modern TCM, physicians first differentiate missed periods from physiological

causes such as pregnancy, breastfeeding or menopause. They also take advantage
of modern techniques to exclude structural defects and identify whether it is
applicable for TCM treatment.

TCM treatments for missed periods are generally indicated for conditions that are
mostly due to dysfunction in the hypothalamus, the pituitary gland, the ovaries or the
uterus. Structural deformities such as birth defects are not applicable.

The hypothalamus-pituitary gland-ovaries-uterus axis.

Thus the hormonal system has a major part to play in the development of this
condition, with doctors usually prescribing hormone therapy to regulate menstrual
cycles.

Actually, amenorrhea is just a symptom; the underling problem can arise from
multiple factors, and individuals can present with various forms of associated
symptoms. For example, individuals with hormone disorders may have excessive
body and facial hair, acne, unusual breast secretions, dry skin, sensitivity to cold
temperatures, a change in voice or sex drive, weight gain, or weight loss.

You should consult a gynecologist if your first menses have not come by age sixteen.
For secondary cases, if missed periods are not due to physiological factors such as
pregnancy or menopause, and last for more than three cycles, you should also seek
medical advice.

During consultation, doctors will obtain a detailed history and perform a physical
exam. Investigations like blood tests, x-rays, ultrasound scans, as well as
chromosome testing may also be necessary. The following are frequently asked on
the first visit:

 The last menstrual period date

 The pattern of your menstrual cycles
 Whether you are sexually active
 Pregnancy history
 Birth control method
 Eating habits
 Emotional state
 Exercise program
 Current medication

Amenorrhea is rarely caused by a life-threatening condition. In most secondary

cases, the underlying problems are reversible and treatable; treatments include oral
supplemental hormones, surgery or simply a change in lifestyle.

How TCM Views the Development of Amenorrhea

In TCM, causes for amenorrhea or missed periods are nothing more than factors
like emotions, diet, blood deficiency, and evils invasions such
as dampness andcoldness. These factors cause disharmonies in
the heart, liver, spleen andkidney, as well as dislocation of the two extra meridians,
the Thoroughfare Vesseland the Conception Vessel. The result is
that blood and qi (vital energy) do not flow through the extra meridians smoothly, so
they cannot reach to the uterus and form menses.

In order to facilitate clinical management, physicians usually differentiate the

pathological changes of the body as either deficient or excess states.

Pathological development of missed periods from a TCM perspective.

Deficient states that result in the development of amenorrhea:

 Deficiency of kidney-qi: kidney-qi is regarded as the power for menstruation in
TCM. When kidney-qi deficiency occurs, the kidneys will then fail to produce a
substance called tian gui, and the blood will not flush the Thoroughfare Vessel
and Conception Vessel. This usually happens in aging, chronic illness or
miscarriage.
 Deficiency of kidney essence: kidneys store the essence; blood and essence
are mutually transformed. Essence is the important source for blood formation.
When there is inadequate essence, blood cannot accumulate in the uterus, and
no menses are formed. This usually happens with overwork and after multiple
pregnancies.
 Deficiency of spleen and stomach: this means that the body's digestive and
absorption functions are abnormal, which leads to poor transformation
ofnutrient essence for the production of blood and qi (vital energy). This
usually happens with stress, overwork and an improper diet.
Excess states that result in the development of amenorrhea:
 Stagnation of qi and blood: This is usually due to emotional disorders. TCM
believes normal emotional health depends on a smooth flow of qi (vital energy)
and blood, which are mainly regulated by the liver. In cases of emotional
disturbances, especially frustration and anger, the liver's regulating functions
are impaired and a condition termed"stagnation of liver-qi" results. When
internal qi and blood flow become disharmonious, the extra meridians are
affected and the menses will not come regularly.
 Obstructions in the extra meridians: When the body is attacked by exogenous
evils like coldness and dampness evils, they tend to congeal and stagnate in
the Thoroughfare Vessel and Conception Vessel, and therefore disturb the
blood and qi flows. On the other hand, dysfunction in the spleen or kidney leads
to phlegm and dampness formation internally. When they accumulate in the
extra meridians or uterus, blockages form.
 Excessive heat: this is a rare phenomenon, when the body has accumulated
excessive heat evils, they dry up the blood fluid and cause missed periods.

The table below provides a general reference for TCM pathological conditions that
cause amenorrhea and their corresponding western diagnosis.

TCM Syndrome Patterns Western Diagnosis

1. Kidney deficiency Poor development of ovaries
Emotional and physical stress
Chronic (long-term) illness
Major bleeding during delivery or
miscarriage
Long-term breastfeeding
Infections of the reproductive organs
Postpartum pituitary insufficiency
2. Hyperactive fire due to yin Ovarian problems such as premature
deficiency ovarian failure (menopause before age
40)
3. Kidney deficiency and phlegm Polycystic ovarian disease
obstruction
Endocrine disorders such as Cushing
Syndrome
4. Yin deficiency in the liver and Pituitary tumor
kidneys
Galactorrhea amenorrhea syndrome
5. Stagnation of blood and qi Miscarriage or delivery that causes
damage to the uterus
6. Dysfunction in the heart, spleen and Anorexia
kidneys
Emotional and physical stress
Acupuncture Therapies for Amenorrhea
Acupuncture activates the flow of qi (vital energy) and removes blockages in
themeridians. For individuals with amenorrhea, stimulation is focused on the Spleen
Meridian and the Conception Vessel so that the production of blood and qi is
ensured and they flow to the uterus as well.

1. Body acupuncture

The major acupoints are: zhong-ji, shen-yu, tai-chong, san-yin-jiao and xue-hai.
(See the graphics for references.)

Additional acu-points are added in different disharmony patterns:

 Deficiency in liver and kidney: gan-yu;

 Deficiency in blood and qi: zu-san-li, tian-shu;
 Stagnation of blood and qi: ji-men;
 Obstruction of phlegm and dampness: feng-long.

Apply daily with an even technique and retain the needles for 20 minutes in each
section. Ten times make up one course. Anaylsis: zhong-ji is for regulating
Conception and Thoroughfare Vessels; xue-hai and tai-chong can relieve liver
stagnation; san-yin-jiao stimulates blood circulation, and shen-yu enriches yin and
reinforces the kindeys.
2. Auricular acupuncture

The auricular points for amenorrhea treatment are: endocrine, ovary, uterus, brain,
liver and kidney. (See the graphic for references.)

When using filiform needles for stimulation, apply daily and select 4-5 points on one
ear, retaining the needles for 20 minutes. The points can also be stimulated by ear
pads or by dermal needles.
Acu-points in the ear